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Avoiding the Medicare Quality Reporting Penalty in 2015

Prepared and reprinted with permission by the Alameda-Contra Costa Medical Association As part of the Physician Quality Reporting System (PQRS), Medicare will impose a 1.5% penalty in 2015 on physicians and other providers who do not successfully report at least one individual quality measure for at least one patient in 2013. The purpose of this article is to help physicians avoid the penalty in 2015 by providing guidance on how to report at least one measure for at least one patient using Medicare claims. Since most physicians already submit Medicare claims for reimbursement, adding the additional PQRS reporting information to the claim will be the least burdensome way for most physicians to avoid the penalty. This article also touches upon how physicians can qualify for a quality reporting bonus and discusses some additional PQRS reporting options. However, this article is not intended to be an exhaustive discussion of PQRS, and resources are listed at the end of the article for those desiring additional information.

Avoiding the Penalty in 2015 through Claims-Based Reporting

For many physician practices not yet participating in PQRS, the simplest way to avoid the penalty in 2015 will be to report on one quality measure for at least one patient (preferably a few patients) on your Medicare claims. The process can be broken down into three steps: 1) selecting an appropriate measure; 2) identifying your Medicare patients to whom the measure applies; and 3) reporting the quality measure on your Medicare claims after an applicable patient encounter.

Step One: Select an Appropriate Measure Quality measures form the basis of the PQRS program, and are intended to provide information to Medicare about an aspect of care, such as prevention, chronic- and acute-care management, procedure-related care, resource utilization, and care coordination. For purposes of avoid40 | THE BULLETIN | SEPTEMBER / OCTOBER 2013

ing the penalty in 2015, physicians should select a quality measure relating to an aspect of care that you will encounter in your Medicare patient population. Review the list of individual measures that are reportable by claims on page 42, and select the most frequent measure that applies to your Medicare patients. Although there are many individual measures that can be reported via claims, some physicians may not find specialtyspecific measures. Nevertheless, there may be a measure that reflects a general aspect of care that is not specialty-specific that may be applicable and can be reported for purposes of avoiding the penalty.

Step Two: Learn the Details for Each Measure After you have selected which measure to report, it is important to review the specifications for the measure with your billing staff. This will help ensure that eligible Medicare patients are appropriately identified and quality measures are accurately reported on claims. Measure specifications are developed by the Centers for Medicare and Medicaid Services (CMS), and can be accessed online at Although the details vary across measures, each measure specification developed by CMS shares a common format and provides important information about: which Medicare patients are eligible for reporting the measure based on patient demographics (age and gender), diagnosis (ICD 9 codes), and primary service(s) provided (CPT codes); the various “quality codes� that are used for reporting on Medicare claims; and, the clinical rationale and information about the measure. It is important to review this information carefully since compliance with these specifications is required for measures you report to be counted. For example, you will not get credit for reporting if the Medicare patient is outside of the age range indicated or whose diagnosis code is not listed on the measure specification. Step Three: Start Reporting on Your Medicare Claims Once you understand which Medicare patients are eligible and the

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